The Rail Accident Investigation Branch (RAIB) today released its report into a train passing over Lydney level crossing with the crossing barriers raised, 23 March 2011.
A full copy of the report is available here:
Summary
At approximately 14:24 hrs on Wednesday 23 March 2011, the 13:45 hrs train from Cardiff to Nottingham, passed over Lydney level crossing while the barriers were in the raised position. This crossing is on the main line between Gloucester and Newport, and carries a road serving an industrial area. The railway signal protecting the level crossing was showing green, and the train was travelling at 59 mph (94 km/h). The red flashing lights intended to instruct road users to stop were operating and there were no road vehicles on the crossing, although the incident occurred at a time when the road was relatively busy with vehicles going to and from factories. No injuries or damage resulted from the incident.
The crossing barriers are controlled by a crossing keeper located in a crossing keeper’s box adjacent to the crossing. The barriers are normally raised and lowered by motors controlled by buttons in the crossing keeper’s box. If the barriers do not operate as required, it is possible for the crossing keeper to push them up or down by hand. Shortly before the incident train arrived, and just after another train had gone over the crossing, the crossing keeper pressed the ‘raise’ button. The barriers did not respond, so the crossing keeper raised the barriers manually.
The RAIB investigation identified a number of factors including:
- the crossing keeper assumed, possibly due to previous problems with equipment at the crossing, that the barrier motors did not respond to the ‘raise’ button because of a defect, rather than because another train was approaching;
- the buzzer which advises the crossing keeper of approaching trains did not give the usual warning and, possibly because of defective equipment, the crossing keeper did not observe an indicator advising him of an approaching train;
- the level crossing was designed so that, once the barriers had been lowered for a train, the protecting signals would clear for a subsequent train without the crossing keeper operating any controls;
- deficiencies in Network Rail processes meant that written instructions to staff did not make clear that Lydney crossing keeper must contact the Newport signaller, and this signaller must put protecting signals to danger, before it was safe to raise the crossing barriers by hand;
- routine competency checks did not reveal that some Lydney crossing keepers, were unaware that railway safety depended on them contacting the signaller before raising the barriers manually; and
- underlying the above, Network Rail’s level crossing risk assessment process did not recognise, and then mitigate, risks associated with the equipment provided at Lydney level crossing.
Since the incident, Network Rail has:
- corrected the defects associated with the indicator intended to advise the crossing keeper that a train is approaching; and
- issued instructions to Lydney crossing keepers, and to Newport signallers, describing the correct procedure to adopt when Lydney crossing barriers are being operated manually.
Network Rail expect to replace the equipment at Lydney level crossing in late 2012, as part of a larger signalling replacement project. The decision to do this had been made before the incident.
Recommendations
As a consequence of this accident, the RAIB has made three recommendations targeted at Network Rail covering:
- improvements to the process for the routine reviewing and updating of both box instructions and the related training material;
- improvements in the process used to verify that staff, such as crossing keepers, have the necessary safety critical competencies; and
- modifying the design of new and updated crossings so that the protecting signals automatically show a stop aspect if the barriers are raised manually.
Notes to editors
1. The sole purpose of RAIB investigations is to prevent future accidents and incidents and improve railway safety. The RAIB does not establish blame, liability or carry out prosecutions.
2. The RAIB operates, as far as possible, in an open and transparent manner. While our investigations are completely independent of the railway industry, we do maintain close liaison with railway companies and if we discover matters that may affect the safety of the railway, we make sure that information about them is circulated to the right people as soon as possible, and certainly long before publication of our final report.
3. For media enquiries, please call 020 7944 3248.
Newsdate: 15 November 2011
